Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
1
+
Amphetamine-Type Stimulants (ATS)
Dr Jonathan BrettClinical toxicology and addiction medicineSt. Vincent’s Hospital Sydney
+Amphetamine-type stimulants
What are they?
Why are they addictive?
Specific substances
Drug testing
Harms
Treatment Withdrawal management
Relapse prevention
SCII.001.001.0001
2
+ Amphetamine-type stimulants
1. Synthesised Compounds
Pharmaceuticals• Pseudoephedrine • Dexamphetamine• Methylphenidate (Ritalin®)• Diethylpropion (Tenuate®)• Phentermine (Duromine)
Illicitly produced• Amphetamine sulphate i.e.
speed• Methamphetamine
e.g. ice, base, speed• Amphetamine analoguese.g. MDMA (Ecstasy), PMA
Tobacco (nicotine) CaffeineAdrenaline CocaineKhat GuaranaCocoa (chocolate) Others...
2. Naturally Occurring Compounds
+ Why are Psychostimulants so Popular?
They feel good!
Elevated mood – euphoria
Enactogen/emphathogen: experiences of emotional communion, oneness,
relatedness, emotional openness
Confidence
Alertness
Increased stamina and energy
Reduced need for sleep
Increased libido
Reduced appetite
Enhanced task performance
Increased physical strength
Increase talkativeness
SCII.001.001.0002
3
+Structure-Activity Relationships
Methyl group substitution increases bioavailability and potency
Methamphetamine
aaa
Amphetamine
aaa
Amphetamine MethamphetaminePhenethylamine
+Structure-Activity Relationships
Amphetamine3, 4 MethyleneDioxy-MethAmphetamine (MDMA)
aaa CH 3
I NH
SCII.001.001.0003
4
aaa
+aaa
Weakly inhibits Mll.O
0
direct agonist
activity
-Some dired receptl,,--~-------'
Inhibits VMJI.T increases cytosolic
Blocks reuptake by Dll.T Syrnportexchange
Dopamine Release
0 1 2 3 4
Time (h)
- Food - Sex EtOH - Nicotine - Morphine - Cocaine - Methamphetamine
5
Chris Hurt. Reprinted with permission. Adapted from Rawson, R. FRONTLINE: The Meth Epidemic. 2006.
SCII.001.001.0004
5
+Terminology
Misuse/extra-medical use
Dependence
Substance Use Disorder
Brain reword pathways
Preftontal oortex y
PFC
OFC
NucNMJS accumbens
El Non-addk:ted brain
Control& sett-regulation
(PFC, CG)
t
II Addicted brnln
NOT Go
CD-
Control& 5ett-regulatloo
(PFC, CG) ";
l
TENTH REV ISION
0 ICD-10 is a new code set for reporting
medical diagnoses & inpatient procedures.
SCII.001.001.0005
6
+Terminology
Dependence = ≥3 of:
Strong desire to take
Difficulties controlling (onset, termination, levels)
Withdrawal
Tolerance
Neglect of other interests (salience)
Persisting use despite harms
Substance use disorder
Taking in larger amounts
Not being able to cut down/stop
Time consumed
Cravings/urges
Work/school affected
Relationships affected
Neglect of other activities
Persisting use despite harm
Tolerance
Withdrawal
Mild = 3, Mod =4-5, Sev = ≥6
+
Amphetamine and methamphetamine
'Ice 'epidemic': Prime Minister Tony Abbott announces task force to tackle crystal meth 'menace' ., ___ """"" __ _ The Primo Mlo~ .. , hnla~nclled•natlonal INklorcetohalptacklothagrowlngand
:;:i~n~::"1c~.crys,.l..........,p,_,,I,,.,
SCII.001.001.0006
7
+ Methamphetamine (“crank”)
Powdered (meth)amphetamine (“speed”) Typically snorted or injected
Base methamphetamine (“base”) Waxy, oily resin Typically injected
Crystalline methamphetamine (“Ice”) Typically smoked
Methamphetamine pills (“Fake ecstasy”) Typically ingested
Purity -FIGURE 15: Annual median purity of methylamphetamine samples, 2004--05 to 2013-14
- NSW - VIC OLD - SA - WA - TAS 100
90
80
70
l 60
~ 50 ·c: cf 40
30
20
10
0
i ! ... ~ I i
N .., ....
i ... J 1 ~ ;i, ~ ~ ~ ~ ~ ~
SCII.001.001.0007
8
+Kinetics
Route Dose Bioavailability Cmax (µg/l)Tmax(minutes)
T1/2(hours)
Time to peak effect
Intravenous 30mg* 100% 108 6 9.1 <15
Smoking 30mg 67% / 90±10% 47 150 12 18
Oral 30mg 67% 94 216 9.1 180
Intra‐ nasal 50mg 79% 113 169 11 ≤15
Cruickshank CC, Dyer KR. A review of the clinical pharmacology of methamphetamine. Addiction. 2009 Jul;104(7):1085-99.
*typical dose
+Metabolism
50%
Methamphetamine
I °'NH2
Amphetamine
vY Phenylacetone
HO ~ 4-Hydroxyphenylacetone
~ ' HOV I
4-Hydroxymethamphetamine
~ NH2
HO~ I ~ 4-Hydroxyamphetamine ~ I NH2
OH
OH / HO "'--~ NHz / 4-Hydroxynorephedrine
u 1 Norephedrine
0
(Y'oH Benzoic acid
~ Nl(OH
V H 0 Hippuric acid
SCII.001.001.0008
9
+Methamphetamine clearance
Amino group on side chain - basic
Acidification of urine promotes net excretion (ion trapping)
Uncontrolled urine pH - 30% excreted unchanged in first 24h
Acidified urine – 75% excreted unchanged in first 24h
+Laboratory testing
Matrix DoseLLOQ/cut‐off (µg/l)
Typical detection time (single dose)
Maximum detection time (repeated dosing)
Plasma10mg intravenous 1 36–48 Not reported
Plasma35mg intravenous 1 36–48 Not reported
Plasma10mg oral, slow‐release 2.5 24Not reported
Oral fluid10mg oral, slow‐release 2.5 243 days
Urine10mg oral, slow‐release 2.5 877 days
Urine 22mg smoking 300 60Not reported
Cruickshank CC, Dyer KR. A review of the clinical pharmacology of methamphetamine. Addiction. 2009 Jul;104(7):1085-99.
*Reactivity of assays variesbetween commercial assays
H I N- CH3
SCII.001.001.0009
10
+How are drugs tested for?
Matrix Blood, urine, oral fluid, hair, primary substance
Immunoassay First line screening High throughput Binding of drug to antibodies Cross reactivity issues
Chromatographic techniques Confirmatory Gas/liquid Separate out compounds Detect – colour (Liquid or gas chromatography), molecular mass
(mass spectrometry) Reference standards vs reference libraries Lower limits of quantification
+Hair
Hair growth 1cm / month
Estimates only made in months (per cm)
May appear in hair 24-48h after use
Cut off for amphetamines 0.5ng/mg
Pitfalls Racial bias
Cosmetic hair treatments
Passive contamination – metabolite ratios, decontamination
SCII.001.001.0010
11
+Oral fluid
Roadside testing
Depends on ability of drugs to filter across mucous membrane – amphetamines ok
Pitfalls Particulates/blood in mouth
Heat instability
Oral contamination
Oral fluid versus serum (for amphetamines) Accuracy 93.1%, positive predictive value 81.4%, negative
predictive value 98.9%
+Drug checking (aka ‘pill testing’)
Primary substance testing
On-site at festivals vs fixed site testing
Range of assays: Fourier-Transform Infra-red spectroscopy (FTIR)
Mass reduction techniques
Thin layer chromatography
Combined with harm reduction messages
Initial results from Australia and UK promising 1 in 5 disposed drug, 1 in 6 moderated intake
1 in 5 not as sold or acquired (2x more common if inside venue) – of these 2 in 3 disposed drug
Measham FC. International Journal of Drug Policy. 2018 Dec 9.
SCII.001.001.0011
12
+Natural history MA useVMAX
Lanyon C, Journal of addiction medicine. 2019 Mar 1;13(2):159-65.
+Natural history MA use VMAX
Associations with past-month MA Male Poor physical health
Associations with methamphetamine dependence Poor physical health Low self-perceived social support Current mental health medication prescription Current engagement with drug treatment services for
methamphetamine use.
Engagement with treatment and health/support services low (12%–22%) over the study period.
Lanyon C, Journal of addiction medicine. 2019 Mar 1;13(2):159-65.
TABLE 2 Methamphetamine Use and Dependence Trajectories Over 5 Years
Past -month se ot Me0,amphetami ne eslt o)'
Consistent past-month use Past-month ~e to abstinenoc Past-month ~e, abstincnoc, return to use
1eth:uuphetamine Dependence (SO, Score ~ 4)
ever dependent ondependcnt, dependent, noo-dependent
Consistently dependent Dependent, non-dependent, dependent
Ol dependent 10 dependent Dependent to non-dependent
SOS, Severity of Dependeooe.
11 = 102, II ( o)
45/102 (44) 43/102 (42) 14/102 (14)
28/102 (27) 2/102 (2)
23/102 (23) 5/102 (5)
13/102 (13) 31/102 (30)
• All paniciparus reported pasi-month methamphelamine use a t baseline, per study inclusM>n criteria.
SCII.001.001.0012
13
+Natural history MA useVMAX
General practitioners most common source of professional support (24%)
Service utilisation associated with: riskier methamphetamine use patterns (e.g., injecting),
professional support access for other issues (e.g., mental health),
greater experience of methamphetamine-related harms (e.g., adverse social consequences).
Quinn. Journal of substance abuse treatment. 2013 Aug 1;45(2):235-41.
+
‘Dance party’ stimulants
MDMA & novel psychoactive stimulants
SCII.001.001.0013
14
+MDMA
Synthesized by Merk 1912 – diet pill,
Psychological warfare 1950 (US army),
Psychotherapy 1970s
Clubbing scene since 1980s
Risk of dependence low
Risks of other harms: Hyperthermia Seizures Electrolyte disturbance (low sodium) Liver injury
+LuckyDip
Tanner-Smith, Drug and alcohol dependence83.3 (2006): 247-254.
Pharmacological conteni of ecstasy tablets: 1999- 2005 Dance-Safe postings
Tablets with this Tablets with this ingredient only ingredient in pan ("/,) ("/,)
MDMA 38.96 54.04 S-MeO-DiPT .66 .66 Acetaminophen .58 1.73 AIIUtriptyline 08 08 Amphetamine .25 .33 Aspirin .16 .82 Benzylpiperazine .16 1.48 Caffei ne 2.14 16.56 Carisoprodol .16 .25 Cocaine .OS .33 Codeine .08 .25 Dextromelhorphan (DXM) 4.94 7.99 Diazepa.m .33 .41 Dietbylpropion 08 .08 Diphenhydra.mine .41 .66 Dimethoxyamphetamine (DOB) .OS .OS Guaifenesin .33 .91 Heroin 0 .OS Ketamine .41 2.n Lidocaine .OS .16 Methylenedioxyamphf'lamine SJ9 1260
(MDA) Methylenedioxyethylamphetamine .91 Si l
(MOE) Mf'tandienone .OS .JJ Methamphetamine 1.48 8.65 Methyl s.alicylate 16 1.48 Phencyclidine (PCP) .OS us Paramethoxyampbetamine (P11A.) .16 .16 Pseudo-ephedrine LIS 7.58 Trifluoromethylpbenylpiperazine .OS 1.32
monobydrochloride Unknown 10.87 11.78 Zolpidem 16 .16
SCII.001.001.0014
15
+MDMA kinetics
+Novel psychoactive substances
<o~1
""' NHCH3 __ c_w_2_0_6_ •ti Hox;n::~ NHCH:i
0 ,✓,; CH 3 ,,,;; CHJ HO
MOMA HHMA
1CfP286 1CYP286
(/)
80
70
60
~ 50 0 ai 40
.0
E ~ 30
20
10
CYP206 HOx;r(Nfii ----► I
,,-:;:, CH3 HO HHI\
2005 2006 2007 2008 2009 2010 2011 2012 2013
Figure 1 Number of novel psychoactive compounds notified for the first t ime to the European Early Warning System since May 2005. Data by EMCDDA (2013, 2014a).
SCII.001.001.0015
16
+
Phenethylamine
+
Others e.g. PMA PMMA 4-MTA TMA TMA-2 2MA 3MA
Amino-indans e.g.
2Al 2AT MMAJ
+
Methylenedioxy-phenethylamines
Ring substiluted methylene-dioxyphenethylamioes
2C Series Others ~ ketonated MOMA e.g. cathinones e.g. e .g. substituted MDEA DOB e.g. e.g. 2CB Mesc.aline methylene MDA DOC bromo- mephedrone 2CI Tyramine dioxyphene DOI dragon- methedrone 2CD Dopamine thylamines Amino DOM Fly methcathinone 2CT-2 e.g. indans DON (ABDF) DOEF DOE'f 2C-B-
bupropion 2CT-7 N-beozyl
ethylone e.g. flephedrooe 2CP methylene MDAI ethcathinone 2CE
derivatives 51Al
DOPR Fly DOTFM Aleph- I
2CN e .g.
MOPY MBDB Pyrrolidioe 2CT-8
2CBCB-MDPPP
derivatives 2CT-9 BOMe
6APB Aleph-6 e.g. 2CT-21 6APDB Aleph-7 oPPP 2CF Ariadne MPPP 2cc Beatrice MOPPP 2C-TFM G3 Naphyrooe G5
PMA: 'not just at Warning over fake ecstasy tablets after story' seven people die in Scotland
DNEWS CJ Just In Politics World Business Sport Science Health Arts Analysis F
Ill, Print 181 Email ll Facebook CJ Twitter Iii More
Potentially lethal 'Superman' drug could be on sale in Australia, police warn Updated 25 Feb 2015, 5:13pm
sin logos
'death'
iwing the death of a 25
-'fl9" .
' I . . iJ. 4 Some of the fake ecstasy tablets, which contain the dangerous stimulant PMA, are green and bear an imprint of the RoleK logo. Pholograph, PoLice Scotland/PA
SCII.001.001.0016
17
+Challenges
Legislation
Ease of derivative manufacture
Laboratory analysis
Lack of clinical experience and unknown toxicities
Marketing and regulation
+
ADHD medicationsMethylphenidate and dexamphetamine
SCII.001.001.0017
18
+
2004 2006 2008 2010 2012 2014
0
50
100
150
200
Nu
mb
er
of e
ve
nts
Methylphenidate Dexamphetamine
MethamphetamineAtomoxetineModafinil
2 0 0 4 2 0 0 6 2 0 0 8 2 0 1 0 2 0 1 2 2 0 1 4
0 .0 0 0
0 .0 0 1
0 .0 0 2
0 .0 0 3
Y e a r
Illi
cit
Ca
lls
/All
In
ten
tio
na
l C
all
s
O b se rve d
2 0 0 4 -2 0 1 4 A P C = 1 3 .7 6^
‘Illicit use’ calls to PICCalls to PIC
+Who?
Surveys (U.S.) National: 3.4% of those aged 12 years and older had experienced
nonmedical use of ADHD medications.
University/college students:
life-time prevalence 7–17% prescribed stimulant misuse Vsgeneral population (0.3–2.1%).
Improve concentration, ‘get high’
EDRS - NDARC: regular ecstasy users (Australia): 90% diverted (non-prescribed) – friend, relative, dealer
50% illicit lifetime
30% illicit in the last six months
ADHD medication overdose and misuse: the NSW Poisons Information Centre experience, 2004-2014
Cairns R, D8Iliels B, Brett}. MJA M8ICh 2016
.. ... + ... +
SCII.001.001.0018
19
+ADHD medications: Why?
Cairns et al. 2016
+Polydrug use
Polydrug use is the norm (88%) for amphetamine users
Use of nicotine, benzodiazepines, analgesics, alcohol is common
Cocaine and concurrent alcohol use is popular because their combination creates cocaethylene which has an extended half-life (from 30 minutes to 2 hours)
Most psychostimulant users tend to use other drugs to medicate the ‘come down’ (CNS depressants)
2004 National Drug Strategy Household Survey
3.0
2.0
-a- Methylphenidate
1.0 ....... oexamphetaimine
--- Modafini t
....... AcomoxetlnE!
0 ■ ■ ■ ■ ■ ■ ■ ■--- ■ ■
.004 2006 2008 2010 2012 2014
Year
SCII.001.001.0019
20
+
Amphetamine-Type Stimulant harms
Harm caused by drugs 100-maximum
Alcohol
Heroin
Crack cocaine
Methamphetamine
Cocaine
Tobacco
Amphetamine
c.annabis
GHB
Benzodia,epenes
Ketamine
Methadone
Mephedrone
Butane
Qot
Anabolic steroids
Ecstasy
LSD
Buprenorphine
Mushrooms
10 20 30
Source: "'Drug harms in the UK", by David Nutt et.at. Thel.anat
40
~ng ---md
• Harm to others • Harm to users
50 60 70 80
-
SCII.001.001.0020
21
+Number of deaths in which illicit amphetamines were detected post-mortem NSW by quarter 2003-2013
McKell & Burns NSW Drug Trends 2013 NDARC, Sydney 2014 p73, data source Forensic Toxicology Laboratory database, NSW Health
Amphetamine hospital episodes
R. McKetin & J. McLarenThe Methamphetamine Situation in Australia:A review of routine data sourcesNDARC Technical Report No. 172
4% 3%
•. 52%
□ Psychos is
l!I Dependence
la Harmful use
D Intoxicat ion
□ Withdrawa l
■ Other/unspecified
-
SCII.001.001.0021
22
+ STIMULANT PSYCHOSIS
Tactile hallucinations (formication or “cocaine bugs”)
Suspiciousness, paranoid delusions
Auditory hallucinations (“voices”)
Visual (‘snow lights”), gustatory, olfactory
Repetitive, compulsive behaviour common
Mood - fearful, agitated, often labile
Orientated but no insight
Violent behaviours
• Prevalence (Sydney)• 13% overt
• 25% ‘prepsychotic’
• Behavioral sensitization
• Reverse tolerance
• Kindling
• Cross sensitization
Ujike, H. Current Psychiatry Reports 2002, 4:177–184
McKetin, Rebecca, et al" Addiction 101.10 (2006): 1473-1478.
Stimulant psychosis
--METH psychOses (human)
iPhenotype
!Brain pathology
Re lapse
Psychoses/craving
Susceptibility to relapse of psychoses I
tttttttttt t t
Chronic schizophrenia
iPhenotype
!Brain pathology
Abuse of METH
Psychotic symptoms
Re-use Stressors of METH
Re lapse
Prodro~ ~nl'1n<N>nnl•s sensitization
period I
I I I Stressors
Stimulant use Discontinuance of medication
SCII.001.001.0022
23
+Toxicological
Generally: Sympathomimetic Syndrome
Seizures
Hyperthermia
HTN, atherosclerosis and ACS
Cerebrovascular event
Cardiomyopathy (reverse takotsubo)
Rhabdomyolysis
Acute liver and kidney injury
Specifically Amphetamines smoked, cocaine:
‘Crack lung’
MDMA: Hyponatraemia
+Executive and memory function impairments
Impairments in executive function (working memory, cognitive flexibility, inhibitory control) and visual memory functions
Amphetamine use disorder > opioid use disorder
No difference in current UD and abstinent ≥ 1 year Long term impairment
Ersche. Neuropsychopharmacology. 2006 May;31(5):1036.
2.5
;,, 2.0
~ ~ ~ 1.5 - 0 !? a. Q. ..
I 1 1.0 .. 0
~"' J 0.5
--o-- Amphetamine
• •>.• • Opiate
~ .. -- Control
O+---~-~--~--~--~-~ 1-move 2-moves 3-moves 4-moves 5-moves 6-moves
SCII.001.001.0023
24
+Risky behaviors
Injecting and sexChemsex
Blood Borne Viruses: HIV, HCV, HBV
Association with HIV independent of behavior and faster HIV progression
Injuries: MVA, burns
Child safety issues
+Impact on society
Significant rates of increase in: Poverty Domestic Violence Crime Assaults Absenteeism Maternal effects on foetus
SCII.001.001.0024
25
+Driving
Acute/chronic use increased dangerous driving RR 8.67 (95% CI 3.23 - 23.32) for crashes resulting in property damage,
RR 6.19 (95% CI 3.46 - 11.06) for injury accidents,
RR 5.17 (95% CI 2.56 - 10.42) for fatal accidents
Cognitive functions such as working memory and movement perception can be impaired
Prospective studies of driving impairment <10x less than used in real-life
Blood cut-off values proposed: 20 to 600 ng/mL for amphetamine,
20 to 200 ng/mL for methamphetamine,
20 to 300 ng/mL for MDMA
Busardo Current neuropharmacology. 2018 Jan 1;16(1):84-96
+Driving
878 cases with amphetamine only drug present in the blood samples of impaired drivers
73% of cases were judged as impaired
Ceiling effect above 0.27-0.53 mg/l
Busardo Current neuropharmacology. 2018 Jan 1;16(1):84-96
SCII.001.001.0025
26
+
Treatment
+Treatment seeking
5 year gap between problem use and treatment seeking
More likely to see treatment if: Riskier use (eg IV)
Seeking support for other problems (eg mental health)
Less likely to seek treatment if Women,
Born outside Australia,
Full-time employed
Non-injectors
Perception of use as non-problematic even if dependent and experiencing MA-related harm
B. Quinn et al 2013 Journal of Substance Abuse Treatment 45; 235–241; Quinn et al 2013 Int J Drug Policy 24(6) 619–623 ; Lee et al 2012 Advances in Dual Diagnosis 5(1)23-31.
SCII.001.001.0026
27
+ Barriers to treatment access
Cumming. Drug and alcohol dependence. 2016 Nov 1;168:263-73.
+Treatment
Harm reduction
Withdrawal management
Relapse prevention
Humber of Ploponloo , ...... .,..,...,. &mltf ,tudlft pooled 11i-a1
11 _.., ts7 It (S< • &S) 322,1, ---20n,g ...... ~, 122 '° (2J. 51) J6 5 incontral d dlug u1•
1 .... • l ct.t•• lO~ en o-, 2 Ill &S) - •-551(5 S2 J
4 llNwJrt olhowlOKCIHltHUI'~ J02 21(U •2) ,,, ... 0..e 10 ktep US"'O MA ,,, ,, (11 27) 17""" ,e __ .,,,_
50(S<-'7) 221% --1 Lie ots - S24 J1121 • 3') 30911, ...
3 ,,, 12(7 11) 596 -"'"""'' 26, 21 (9 34) 402,1, -
10 W•t,,gl1tSI00'°"9 245 It (3 34) 502,1,•
11 T 122 1' 11-251 70 ,,.. --"'" m 31 (21 -SS) 42 0%
1l l.ogii•lc• (work._ chide..,. b•npod) 2 221 19(U-24) 31 5 ---""'-Y '_,.aolty,onc..,.. 2 l2T 511" s,1 2'5 ---15 F .. d llllltr«C )OJ JI (26 • 36)
,. .. ,. '"o«OOi ·- .,POOltd, ........ ••,,co001
SCII.001.001.0027
28
+Harm reduction
Needle syringe programs
Safe injecting rooms
Peer support workers/contact centre
‘Play packs’
BBV screening, vaccination and treatment
PREP/condoms
Pipe distribution (Canada)
+MA withdrawal
DSM-5 stimulant withdrawal: Dysphoria; fatigue; sleep disturbance; increased appetite;
psychomotor agitation or retardation; and vivid dreams
Crash Withdrawal
• 12-24h post cessation• Lasts 2-3 days• Hypersomnia/insomnia• Restlessness• Flat mood• Cravings• Aches and pains
• Lasts 2-4 weeks• Peaks day 7-10• Strong cravings, mood fluctuations,
irritability, restlessness, anxiety, agitation, fatigue, muscle tension,increased appetite, poor concentration.
SCII.001.001.0028
29
+
• 2009: 4 RCTs• Amineptine• Mirtazepine
• No evidence based treatments
• In-patient vsoutpatient
+Treatment
Psychosocial treatmentStandard careGroup work1:1 counseling Contingency managementEffect size 0.28
Pharmacological intervention
Treatment for amphetamine withdrawal (Review)
Shoptaw SJ, Kao U, Hoinz.orling K, Ling W
THE COCHRANE COLLABORATION ®
SCII.001.001.0029
30
+
+Pharmacological intervention
D-amphetamine/Lis-d-amphetamine*
Modafinil
Methylphenidate
N-acetylcysteine
Buproprion
Varenicline
Risperidone
Naltrexone
Efficacy of psychostimula nt drugs for amphetamine a buse or d epe nde nce (Review)
Pin-z..Mana C, Gutell, X. Torren, M, Capella D, Fa.rre M
THE COCHRANE
' -i.) C_ochrane ~. Library
Psychosoc1al interventions for psychostimulant misuse (Review)
Minozzi S,Saulle R,0..CffKfflzo f,Amato L
BJCP British Journal of Clinical Pharmacology
Pharmacological approaches to methamphetamine dependence: a focused review Laurent Karila, 1 Aviv Weinstein, 2 Henri .Jean Aubin, 3
Amin e Be nyamina, 3 Mi chel Reynaudi- & Steven L Batkih
~ ) C_ochrane \:!, Library
Cognltive--behavioural treatment for amphetamlne--type stimulants (ATS)-use disorders (Review)
Harada T, TsutomiH, Mon R,Wilson DB
SCII.001.001.0030
31
+Treatment outcomes:MATES (NDARC) - Sydney
3 year study n=300 treatment entrants – 267 followed up
10% deceased/incarcerated at 3 years
Initial treatment: residential rehabilitation (n =126), counselling (n = 19) or detoxification (n = 51)
+Treatment outcomes:MATES (NDARC) MATES (NDARC)
a. 100
90
i 80
70 ~
i 60
• 50
f .. 30
20
10
8'WIIM J montM 1~,, 3 yHO
b. u u c
t l .4 ~ t:1.2 :!. i I
• 0~ t 0.6
0.4
0.2
Slset.-.e 3 months l yHt 3-;ears
100 ~ ,0
f 80 e 70 i 60
1~ : -s 30 l 20 0 10
j
100 5 90
j : ~ 60 ..__ 50
~ ~ 40 -s 30 l 20 0 10
] 0 8uellne
NotrHltnenl
O.todficat,on
)months ! year
Re$ident~I reNbihation
I
,,..,.
■ ]tdays/wffl
01· 2~ys/wet-k
0 les.s I han Wffkly
■ Noust"
SCII.001.001.0031
32
+Treatment outcomes:MATES (NDARC)
Outcomes: 53% re-entered drug treatment 34% had remitted from dependence without any further drug
treatment 13% were dependent on methamphetamine but had not returned
to drug treatment
Long-term treatment success: Longer treatment duration -counselling and residential rehabilitation
Poor outcomes More frequent use prior to treatment Injecting Psychosis/distress
McKetin Addiction. 2012 Nov;107(11):1998-2008.
+Treatment outcomes:Stimulant treatment program
McKetin. Drug and Alcohol Review 2013, 32, 80–87
I Baseline 3 months 6 months
(11- 105) (11 -86) P-value (11 -83) P-value
Methamphetamine use in the past month Any use (%) 79 53 <0.00 1 55 <0.00 1 Days of use (median) 6 I <0.00 1 I <0.001 Severity of dependence (median SOS score) 7 3 <0.00 1 2 <0.00 1 Dependent (%) 76 47 <0.00 1 39 <0.00 1
Other drug use in the past month (%) Tobacco 78 76 0.999 75 0.999 Alcohol 61 63 0.629 69 0.108 Cannabis 43 38 0.118 42 0.824 Heroin 6 7 0.999 6 0.999 Cocaine 12 2 0.0 16 7 0.508 Ecstasy 17 10 0.791 17 0.832
Health and social functioning in the past month (%) Physical health disability 27 17 0.076 23 0.263 Mental health disability 68 50 0.006 43 <0.00 1 Psychotic symptoms 26 12 0.024 16 0.108 Hostility 4 1 25 0.020 23 0.020 Injected 55 42 <0.001 46 0.001 Injected with used needle 7 6 0.999 2 0.688 Sexually active 70 65 0.383 71 0.999 Unprotected casual sex 22 16 0.581 27 0.648 Crime 30 24 0.701 29 0.999
SCII.001.001.0032
33
+Treatment outcomes:LGBTI
Lea. PloS one. 2017 Feb 16;12(2)
+
Basel ine (n • 101) Follow-up 1 (n • 60) Follow-up 2(n • 32) OR(95% CI)
Methamphetarrine use in past 4 weeks
use (%) 82.2 < .001
Days used (median) 2 .001
SOS"""" (median) 5 < .001
SOS dependence (%) 92.1 78.3 71 .9
Other substance ~ t 4weeks %
Arr,alcohol 70.3 80.0 78.1 1.02 (0 .97- 1.06) .48
MadiLm- or higt-risk alcdlol• 15.8 20.0 18.8 0.94 (0 .90--0.99) .01
_[}ail),1-a:o 23.8 13.3 25.0 0.98 ~ 1.03 .50
cannabis 18.8 0.96 .90-1 .02 .15
Benzodiazepines 28.1 1.03(0.97- 1.09) .39
Cocaine 7.9 12.5 1.01 ~ 1.06 .70
Other iici augs 24.8 25.0 31 .3 1.00(0.93--~ .89 ectii dru USl8 in
Injected any drug 62.5
18.8
27.7 16.7 21 .9
26 16.5 0.04(0.01~ <.001
31 .3 0.83 .n-o.89 <.001
24 9.06 .87- 21.23 < .001
SCII.001.001.0033